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Tight regulation
Introduction Tight regulation (TR) leads to fewer diabetic complications in humans, dogs and cats. In cats you have the benefit of increased levels of remission. The goal of TR is to regulate the human, dog or cat in the range that is normal for a healthy organism of that species ("euglycemia") for as much of the day as possible. Tight regulation was studied in humans in a famous 10-year study called the Diabetes Control and Complications Trial (DCCT) Diabetes Control & Complications Trial (DCCT)National Diabetes Information Clearinghouse-NIHGenetichealth.com-Advantages of Controlling Type 1 Diabetes which compared tightly-regulated diabetics to traditionally-regulated diabetics and their incidence of complications from diabetes. They found that the tightly-regulated patients showed: *76% reduced risk of eye disease *50% reduced risk of kidney disease *60% reduced risk of nerve disease Before the end of the study, all the humans in the control group were moved into the tight regulation group because of the clear indications of reduced diabetic complications and better health. Because of this result, humans were expected to keep their blood glucose level average below 170 mg/dL (9.5 mmol/L) at all times. However, there is newer evidenceDo People With Type 2 Always Deteriorate?-Phlaunt.com that even this level isn't adequate to stop the deterioration of type-2 diabetes and eventual complications in humans. The AACE now recommendsHealthy Blood Sugar Target Levels-Phlaunt.com a level of under 140 mg/dL (7.8 mmol/L) at all times for humans. Dogs In dogs, tight regulation is especially important if the dog still has its eyesight, since blindness can ensue when blood glucose levels stay above 250mg/dL (14mmol/L) for too long. Remaining beyond the renal threshold for glucose for extended periods of time can also mean damage to the kidneys and other vital organs. In many dogs it is possible to achieve TR by using a high-fiber diet combined with strategically-timed shots of NPH or Lente insulins. It is also possible to manipulate feeding times to match the way the individual dog metabolizes the insulin. Most dogs are fed 2 equal portions of food 12 hours apart, and receive their insulin after eating. Some achieve optimum results with a 3 or 4 daily meals pattern, dividing the total food portion this way, with injections remaining on a 12 hour cycle. If TR cannot be achieved this way, the dog should be switched to a basal/bolus regime, similar to that of diabetic humans. There are some dog owners that successfully combine fast or rapid acting insulin (bolus) and intermediate or long-acting insulin (basal), for example. The most common basal/bolus combination for dogs would be use of R//Neutral insulin as bolus and NPH/Isophane insulin as a basal. Those dogs whose blood glucose levels drop lower than desired at peak time are scheduled for a snack to ensure hypoglycemia won't occur. Learning the individual pattern of highs and lows and using them to one's advantage is the key here. Cats Commonly, three insulins are used for TR in cats: *PZI *Lantus *Levemir Lantus and Levemir are very similar in terms of duration and potency. There has been not quantifiable difference between Lantus and Levemir as yet, but there are still too few cats on Levemir to say this with certainty. The following will describe the two most common approaches using these three insulins for tight regulation. If you choose to follow one of these protocols, please inform yourself thoroughly before you start. These protocols don’t just involve giving insulin and measuring blood glucose values, but there are also important dietary prerequisites (a low-carb canned or raw diet) and other factors you should be aware of. On the other hand, these protocols are nothing to be afraid of either and can be used by people new to feline diabetes: all that is required is a thorough understanding of the methods and their careful applicaton. Cats with PZI PZI has a shorter duration than Lantus or Levemir, therefore it is injected mostly TID or QID to keep the cat in the normal range for as long as possible. A good TR protocol for regulating and inducing remission in cats with PZI was developed by Dr. Hodgkins and uses a so-called sliding scale, a basic version of which is as follows: This is BASIC. You may need a little more and in some cases a little less. mmol/l mg/dl interpretation ------ ----- -------------- 2.0 - - 36 - - low, FEED CAT Watch him No insulin needed test in 2 hours 2.5 - - 45 - - low, FEED CAT No insulin needed test in 2 hours 3.0 - - 54 - - Normal No insulin needed test in 2 hours 3.5 - - 63 - - Normal No insulin needed test in 2 hours 4.0 - - 72 - - Normal No insulin needed test in 2 hours 4.5 - - 81 - - Normal No insulin needed test in 2 hours 5.0 - - 90 - - Normal No insulin needed test in 2 hours 5.5 - - 99 - - Normal No insulin needed test in 2 hours 6.0 - - 108 - - High Normal No insulin needed test in 2 hours 6.5 - - 117 - - High Normal No insulin needed test in 2 hours 7.0 - - 126 - - High Normal No insulin needed test in 2 hours 7.5 - - 135 - - High Normal No insulin needed test in 2 hours 8.0 - - 144 - - Give starting dose of insulin. .5U of PZI if you do not have history 8.5 - - 153 - - Give starting dose of insulin. .5U of PZI if you do not have history 9.0 - - 162 - - Give 1U of PZI if you do not have history 9.5 - - 171 - - Give 1U of PZI if you do not have history 10.0 - - 180 - - Give 1U of PZI if you do not have history 10.5 - - 189 - - Give 1.5U of PZI if you do not have history 11.0 - - 198 - - Give 1.5U of PZI if you do not have history 11.5 - - 207 - - Give 2U of PZI if you do not have history 12.0 - - 216 - - Give 2U of PZI if you do not have history 13.0 - - 234 - - Give 2.5U of PZI if you do not have history 14.0 - - 252 - - Give 3U of PZI if you do not have history 15.0 - - 270 - - Give 3U of PZI if you do not have history 16.0 - - 288 - - Give 3.5U of PZI if you do not have history 17.0 - - 306 - - Give 3.5U of PZI if you do not have history 18.0 - - 324 - - Give 3.5U of PZI if you do not have history 20.0 - - 360 - - Give 4U of PZI if you do not have history 22.0 - - 396 - - Give 4U of PZI if you do not have history 24.0 - - 432 - - Give 4.5U of PZI if you do not have history 26.0 - - 468 - - Give 4.5U of PZI if you do not have history 28.0 - - 504 - - Give 5U of PZI if you do not have history This is a good start to bumping up your doses. Whenever you test at at least +6 and get a number above 140, shoot again according to this... This does assume that your cat is on an UPWARD trend BG rising at +6. If your cat commonly continues dropping at +6 then wait and test also at +7 (First +6 then +7 to see trend) and check that he is higher than he was at +6 before shooting. Please see http://www.yourdiabeticcat.com/ for more information and Dr. Hodgkin’s forum. Cats with Lantus and Levemir A good TR protocol has been developed in Germany for Lantus and Levemir. These insulins are injected BID and no sliding scale is used. This protocol has been developed by members of the TR Lantus Levemir Forum. These people originally founded a Yahoo!Group in October 2004 because they had experienced that TR was the best approach for their cats with Lantus. In March 2006, the founders moved to the new forum. The logic for a fixed dose on Lantus/Levemir BID is just this: the peak of these insulins is so late and the effect of the dose so long-lasting (well past the next shot), that the dose size is more likely to affect your next preshot than to have any effect on the immediate situation. Nadirs are frequently measured at +10 to +12 hours after injection. So changing your dose based on immediate numbers doesn't have any relevance: by the time the new dose has an effect, the current number is long-gone. The changed dose just affects the next peak, and you wanted that to be constant anyway. Here are some key features of the protocol: *It works very well in the great majority of cats that it has been used with. *Many owners who have been using Lantus, but not this protocol, have had much more trouble regulating their cats and mostly don’t achieve regulation. *It should be noted that Caninsulin is the only licensed insulin for cats in Germany and virtually all German cats who use this TR protocol are therefore not newly diagnosed diabetics, but medium to longer-term diabetics. They have been hard to regulate, frequently also on other insulins in addition to Caninsulin and have a lot of beta-cell damage due to glucose toxicity. *There have not been any clinical hypoglycemic events under this protocol, while some cats may occasionally have a too low BG. *The measurement of ketones in cats using this protocol is extremely rare: and these events can be counted on one hand and usually resulted from an acute infection before the cat has reached regulation. *All remissions have been extremely stable. *There are several cats that are unlikely ever to go into remission due to complicating factors; the majority of them are well-regulated in the normal range with Lantus/Levemir (mostly 50 to 80 mg/dL, rarely peaking at 100-120 mg/dL). *The protocol for TR with Lantus/Levemir was refined over the years and can be read in its most up-to-date form here: http://www.tillydiabetes.net/en_6_protocol2.htm Links to a number of Excel spreadsheets and one JPG of cats who use this protocol can be found here (they are pretty language-neutral): *Cat1 *Cat2 *Cat3 *Cat4 *Cat5 *Cat6 *Cat7 Additional approaches for cats Some people have had success supplementing their normal insulin with small shots of R/Soluble insulin. R has a very high potency and can therefore be dangerous: you should be closely supervised by a vet if you choose to use this approach. Further Reading *The Feline Diabetes Message Board Tight Regulation FAQ *The FDMB has a separate section for discussion of the tight regulation of diabetic cats *Beyond Insulin Therapy: Achieving Optimal Control in Diabetic Dogs-Drs. Fleeman & Rand-University of Queensland-2005 References Category:TreatmentsCategory:RegulationCategory:TipsCategory:Terms